Workers' Compensation Hearing Request
DECLARATION OF READINESS TO PROCEED / REQUEST FOR HEARING
(Workers' Compensation Administrative Proceeding)
SECTION 1: CASE INFORMATION
CASE/CLAIM NUMBER: [CLAIM NUMBER]
WCAB/BOARD CASE NUMBER: [CASE NUMBER]
DATE OF FILING: [DATE]
FILING PARTY:
☐ Applicant/Injured Worker
☐ Defendant/Insurance Carrier
☐ Lien Claimant
SECTION 2: APPLICANT/INJURED WORKER INFORMATION
Name: [FULL NAME]
Date of Birth: [DATE]
Social Security Number: [XXX-XX-XXXX]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Phone: [PHONE NUMBER]
Date of Injury: [DATE]
Body Parts Claimed: [LIST ALL BODY PARTS]
SECTION 3: EMPLOYER INFORMATION
Employer Name: [EMPLOYER NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Insurance Carrier: [CARRIER NAME]
Claim Number: [CLAIM NUMBER]
Claims Administrator: [NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
SECTION 4: ATTORNEY/REPRESENTATIVE INFORMATION
Applicant's Attorney
☐ Applicant is self-represented (pro se)
Attorney Name: [NAME]
Firm Name: [FIRM NAME]
State Bar Number: [NUMBER]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]
Email: [EMAIL]
Defendant's Attorney
Attorney Name: [NAME]
Firm Name: [FIRM NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]
Email: [EMAIL]
SECTION 5: TYPE OF HEARING REQUESTED
5.1 Hearing Type
I request the following type of hearing:
☐ Mandatory Settlement Conference (MSC)
For settlement discussions and narrowing of issues before trial.
☐ Status Conference
To address procedural matters and case management.
☐ Priority Conference
For urgent matters requiring immediate attention.
☐ Expedited Hearing
Emergency circumstances requiring expedited resolution.
☐ Trial/Regular Hearing
For adjudication of disputed issues on the merits.
☐ Lien Conference
For resolution of medical or other liens.
☐ Rating Conference
To address permanent disability rating disputes.
☐ Other: [SPECIFY]
5.2 Expedited Hearing Request (if applicable)
☐ I request an expedited hearing for the following reason(s):
☐ Applicant is not receiving temporary disability benefits to which entitled
☐ Applicant requires urgent medical treatment that has been denied
☐ Medical condition is deteriorating
☐ Applicant is experiencing severe financial hardship
☐ Other emergency: [EXPLAIN]
Detailed explanation of need for expedited hearing:
____________________________________________________________________________
____________________________________________________________________________
SECTION 6: ISSUES IN DISPUTE
6.1 Issues to Be Decided at Hearing
Check all issues requiring adjudication:
Compensability/Liability:
☐ Whether injury arose out of and in the course of employment (AOE/COE)
☐ Employment relationship
☐ Date of injury
☐ Body parts injured
☐ Statute of limitations
Medical Issues:
☐ Medical treatment dispute (authorization for treatment)
☐ Medical treatment dispute (reasonableness/necessity)
☐ Selection of treating physician
☐ Need for future medical treatment
☐ Self-procured medical treatment reimbursement
Disability Benefits:
☐ Temporary total disability (TTD)
☐ Temporary partial disability (TPD)
☐ Permanent disability rating
☐ Apportionment of disability
☐ Date and nature of permanent and stationary status
Other Benefits:
☐ Supplemental job displacement benefit (SJDB)
☐ Return to work/vocational rehabilitation
☐ Death benefits
☐ Dependency status
Other Issues:
☐ Penalties for unreasonable delay/denial
☐ Interest
☐ Attorney fees
☐ Sanctions
☐ Credit issues
☐ Lien disputes
☐ Settlement approval
☐ Other: [SPECIFY]
6.2 Description of Issues
Provide a brief description of each disputed issue:
Issue 1: [ISSUE]
Position of Filing Party:
____________________________________________________________________________
Issue 2: [ISSUE]
Position of Filing Party:
____________________________________________________________________________
Issue 3: [ISSUE]
Position of Filing Party:
____________________________________________________________________________
SECTION 7: CASE STATUS
7.1 Discovery Status
Discovery is:
☐ Complete
☐ Substantially complete (explain what remains)
☐ In progress (explain status)
☐ Not yet commenced
Outstanding discovery:
____________________________________________________________________________
Estimated completion date for discovery: [DATE]
7.2 Medical-Legal Evidence
QME/AME Status:
☐ QME/AME evaluation completed
Evaluator: [NAME]
Specialty: [SPECIALTY]
Date of Evaluation: [DATE]
Report Received: ☐ Yes ☐ No
☐ QME panel requested, awaiting panel
Date Requested: [DATE]
☐ QME/AME scheduled
Evaluator: [NAME]
Date of Appointment: [DATE]
☐ QME/AME not yet requested
☐ Deposition of QME/AME: ☐ Completed ☐ Scheduled ☐ To be scheduled ☐ Not needed
7.3 Other Medical Reports
Primary Treating Physician Reports:
☐ Available through [DATE]
☐ Additional reports expected
Other Medical Reports:
[LIST OTHER MEDICAL EVIDENCE]
7.4 Depositions
Depositions Completed:
| Deponent | Date | Subject |
|----------|------|---------|
| [NAME] | [DATE] | [SUBJECT] |
Depositions Scheduled or Needed:
| Deponent | Scheduled Date | Subject |
|----------|---------------|---------|
| [NAME] | [DATE/TBD] | [SUBJECT] |
SECTION 8: SETTLEMENT EFFORTS
8.1 Settlement Status
Have settlement discussions occurred?
☐ Yes ☐ No
If yes, describe current status:
____________________________________________________________________________
Settlement demand (if applicable): $[AMOUNT]
Settlement offer (if applicable): $[AMOUNT]
Reason settlement has not been reached:
____________________________________________________________________________
8.2 Settlement Potential
Is this case appropriate for settlement at the requested hearing?
☐ Yes - Case can likely be settled with judicial involvement
☐ No - Trial is necessary due to: [EXPLAIN]
☐ Uncertain - Depends on: [EXPLAIN]
SECTION 9: WITNESS AND EXHIBIT INFORMATION
9.1 Witnesses
Witnesses filing party intends to call at hearing:
| Witness Name | Type | Subject of Testimony |
|---|---|---|
| [NAME] | ☐ Fact ☐ Expert | [SUBJECT] |
| [NAME] | ☐ Fact ☐ Expert | [SUBJECT] |
| [NAME] | ☐ Fact ☐ Expert | [SUBJECT] |
☐ Interpreter needed for witness(es): Language: [LANGUAGE]
9.2 Exhibits
Exhibits filing party intends to introduce:
☐ Medical reports and records
☐ QME/AME report(s)
☐ Employment records
☐ Wage records
☐ Job description
☐ Deposition transcripts
☐ Photographs/videos
☐ Correspondence
☐ Other: [SPECIFY]
Estimated number of exhibit pages: [NUMBER]
SECTION 10: ESTIMATED TIME FOR HEARING
Estimated time needed for hearing:
☐ 15 minutes or less
☐ 30 minutes
☐ 1 hour
☐ 2 hours
☐ Half day (4 hours)
☐ Full day
☐ Multiple days: [NUMBER] days
Reason for extended time (if applicable):
____________________________________________________________________________
SECTION 11: SPECIAL ACCOMMODATIONS
☐ Interpreter needed
Language: [LANGUAGE]
For: ☐ Applicant ☐ Witness(es)
☐ Disability accommodation needed
Type of accommodation: [SPECIFY]
☐ Telephonic/video appearance requested
For: [NAME]
Reason: [EXPLAIN]
☐ Other special request: [SPECIFY]
SECTION 12: CERTIFICATION AND DECLARATION
Declaration of Readiness
I, the undersigned, declare that:
☐ This case is ready to proceed to hearing on the issues specified.
☐ All necessary discovery has been completed or will be completed before the hearing date.
☐ I have made a good faith effort to resolve disputed issues prior to requesting this hearing.
☐ I have served all parties with a copy of this request for hearing.
☐ All statements in this document are true and correct to the best of my knowledge.
☐ I understand that this request will result in scheduling of a hearing, and all parties are obligated to appear.
Certification Regarding Settlement Efforts
☐ I certify that a good faith effort has been made to resolve the issues in dispute.
☐ If this matter cannot be settled, it is ready for trial.
Signature: _________________________________
Printed Name: [NAME]
Title/Capacity: ☐ Attorney for Applicant ☐ Applicant Pro Se ☐ Attorney for Defendant ☐ Lien Claimant
Bar Number (if attorney): [NUMBER]
Date: [DATE]
SECTION 13: PROOF OF SERVICE
I declare that on [DATE], I served a true and correct copy of this Declaration of Readiness to Proceed/Request for Hearing on the following parties:
| Party | Name | Address | Method |
|---|---|---|---|
| ☐ Applicant | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
| ☐ Applicant's Attorney | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
| ☐ Defendant | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
| ☐ Defense Attorney | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
| ☐ Insurance Carrier | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
| ☐ Lien Claimant(s) | [NAME] | [ADDRESS] | ☐ Mail ☐ Fax ☐ Email ☐ Personal |
Signature of Server: _________________________________
Printed Name: [NAME]
Date: [DATE]
SECTION 14: FILING INSTRUCTIONS
Where to File
File this request with:
Agency: [STATE WORKERS' COMPENSATION BOARD]
District Office: [OFFICE NAME]
Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]
Electronic Filing System: [WEBSITE/SYSTEM NAME]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]
Filing Requirements
☐ Original plus [NUMBER] copies
☐ Filing fee: ☐ None required ☐ $[AMOUNT]
☐ Proof of service required
After Filing
What to expect after filing:
- Case will be assigned to a Workers' Compensation Judge
- Notice of hearing date will be sent to all parties
- Typical time to hearing: [STATE-SPECIFIC ESTIMATE]
SECTION 15: STATE-SPECIFIC INFORMATION
California (WCAB):
- File with local WCAB district office
- Use EAMS (Electronic Adjudication Management System) for electronic filing
- DOR must specify whether MSC, status conference, or trial is requested
- Priority conferences available for urgent medical treatment or unpaid TD
Texas (DWC):
- File Request for Benefit Review Conference (DWC-45)
- BRC will be scheduled within 40 days
- If unresolved at BRC, request Contested Case Hearing
New York (WCB):
- File Request for Hearing (Form EC-3)
- Indicate issues in dispute
- Pre-hearing conference may be scheduled first
[YOUR STATE]:
[INSERT STATE-SPECIFIC INSTRUCTIONS]
[END OF DOCUMENT]
About This Template
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: May 2026
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